Mycetoma or maduramycosis is a soft tissue infection caused by fungi or fungus-like bacteria. The infection occurs mainly in dry areas of the tropics. Infection occurs through small lesions of the skin through which the pathogens enter the organism.
What is a mycetoma?
Maduramycosis was first described in the Indian province of Madura, hence the name of the infection. Because the infection usually occurs on the foot – the pathogen typically enters the body through small cracks caused by walking barefoot – the infection is also known as “madura foot.” Maduramycosis occurs in two distinct forms. True mycetoma (Eumyzetoma) is caused by yeast or mold, and actinomycetoma (Actinomyzetoma) is caused by various genera of bacteria (Streptomyces, Actinomadura, Nocardia). Overall, maduramycosis is very common worldwide, with geographic foci. While in Asia and Africa, maduramycosis mostly occurs in the form of eumycetoma, in Mexico actinomycetoma is highly prevalent.
Causes
The cause of maduramycosis is infection with a fungus or bacterium. Infection usually occurs via wood prickles that have entered the foot or via penetration of the fungi or bacteria via small injuries to the foot. The following fungi are possible pathogens for an eumycetoma: all fungi of the genus Madurella, the genus Acremonium, Phialophora verrucosa and Aspergillus flavus. Different bacteria can be identified as the source of an actinomycetoma, namely different species of the bacterial genus Nocardia (mainly Nocardia brasiliensis), different species of the genus Streptomyces (mainly Streptomyces madurae) and Actinomadura. Fungi are responsible for infection in about 40% of all cases, and 60% of all infections are due to infection with bacteria.
Symptoms, complaints, and signs
After an incubation period of several weeks to several months, so-called granulomas develop at the infected soft tissue sites. These are painless nodules that contain the particular pathogen in the form of granular material. At the site of the nodules, there is also massive swelling of the affected body part. The purulent granules are transported to the outside via fistula ducts. The pathogens can be various fungi or bacteria that enter the body through small skin lesions. For example, the feet are often infected because walking barefoot in various population groups causes the pathogens to enter a wound on the foot, for example via wood splinters that have been stepped on. Less frequently, mycetoma is observed on the back, knees, or hands. Despite different pathogens, the symptoms of the disease are similar, so that the term mycetoma can be understood as a collective term. However, depending on the two groups of pathogens, there are differences in the symptoms in addition to the similarities. For example, in a true mycetoma (fungal infection), the nodules are not clearly demarcated from each other. In addition, many fistulas are present. Furthermore, in this form of infection, the bones are often involved at a very early stage. Therefore, it often becomes necessary to surgically remove the affected tissue areas in addition to drug treatment. In the case of infection caused by bacteria (actinomycetoma), the granules are encapsulated from each other, with only a few fistulas developing. Bone involvement is less common in this case. Therefore, surgical removal of affected tissue is rarely necessary in actinomycetoma.
Diagnosis and course
An initial diagnosis in maduramycosis can usually be made based on the clear symptoms. Painless small nodules to massive swellings of the infected area form. Granular secretion is discharged from the nodules or swellings – often without external influence. The physician recognizes an infection clearly after a microscopic examination. The secretion that is discharged is examined. If it is a fungal infection, the secretion has a granular, thread-like, white to slightly yellowish structure. After a clear diagnosis, the physician has a choice of various medications that can be used for therapy. If the drug therapy is applied in time, the course of the infection is quite harmless and, above all, painless.If maduramycosis, especially eumycetoma caused by fungi, is not treated, the infection becomes chronic. The symptoms such as purulent tumors do not heal on their own. In addition, spread to other parts of the body is almost inevitable. At worst, affected body regions must be amputated.
Complications
Infection with the fungi of mycetoma can lead to an additional bacterial superinfection. This means that another disease triggered by bacteria is favored. This can also occur if medical treatment has been given. In most cases, however, complications from a mycetoma are more likely to result from a lack of medical treatment, as the tumor then has the opportunity to infiltrate the inside of the body and continue to grow inside. This can lead to bone destruction, meaning that bone tissue is destroyed. Muscle tissue may also be affected. Adenopathy is also possible. This refers to a disease of hormone-producing glands. Tumors formed by proliferating granulation tissue can form cerebral and visceral metastases. This refers to offshoots in the brain and internal organs. If mycetomas are allowed to grow too long, since they are common, especially on the feet, they may severely limit the ability to walk. Deformities of the ankles can lead to additional movement disorders. If joints, bones and muscles have been attacked too much, an amputation must be performed, which results in further disabilities.
When should you go to the doctor?
Changes in the appearance of the skin, discoloration or a lump should be presented to a doctor. If the symptoms spread or increase in intensity, there is a health condition that needs to be investigated and treated. In the case of swelling, itching or open wounds, the cause should be clarified. If the disturbances result in restrictions of movement or a decrease in mobility, a doctor should be consulted. If the symptoms increase rapidly within a few hours, a visit to the doctor is required as soon as possible. The pathogens spread quickly and the body’s own defense system is not strong enough to defend itself against them to the necessary extent. A decrease in physical performance, internal weakness or a general feeling of malaise indicate irregularities that should be presented to a doctor. If the affected person suffers from the visual changes of the skin or the blemish, surgical removal of the unwanted tissue is necessary. If inflammation of the skin, enlargement of an existing wound or gangrene occurs, a doctor should be consulted immediately. In severe cases, there is a risk of sepsis and thus a potential threat to life. Irritability, behavioral abnormalities, or withdrawal from usual social activities are further indications of an existing illness.
Treatment and therapy
A treatment of a mycetoma is carried out by means of medication indication. An accurate diagnosis is necessary to select the correct drug at the correct dosage. If a fungal infection is present, various antifungal agents are used for treatment. Since many of the fungal cultures are now very resistant or resistant to the antifungal agents, it is essential to monitor the effect accordingly while taking the medication. The medication is usually taken over a very long period of time, usually several years. Beyond the administration of medication, it is recommended to surgically remove affected swollen or purulent areas in order to mitigate the associated discomfort for the patient. If the mycetoma is caused by bacteria, the patient will receive an antibiotic. Even with a bacterial infection, the swelling in the affected areas of the body may not heal. In that case, surgical intervention would also be indicated.
Outlook and prognosis
Nowadays, mycetoma is easily treatable and offers a positive prognosis. The condition must be treated surgically or with medication to prevent the fungus from spreading. If left untreated, maduramycosis can develop into a chronic disease that is associated with numerous limitations in professional and personal life for the sufferer.In the course of the disease, amputations may be necessary, which significantly reduce the patient’s quality of life. Mental illnesses can also develop as a result of an amputation. For example, some patients develop depression or anxiety disorders after losing a body part, which must be treated. Physical complaints such as circulatory disorders or phantom limb pain also occur after an amputation and influence the evaluation of the course. The prognosis is nevertheless good, since nowadays a whole range of therapeutic procedures are available and the fungal disease is usually not fatal. The course of the disease is assessed by the dermatologist or internist in charge, who takes into account the severity of the disease, the patient’s constitution and social factors such as the financial situation of the person affected. If necessary, the prognosis must be adjusted, especially in the case of unforeseen complications, which occur mainly in severe diseases.
Prevention
Mycetoma is very easy to prevent. In areas where mycetoma is common, walking barefoot should be consistently avoided. If small injuries nevertheless occur in the area of the foot, the wounds must be disinfected immediately and permanently. When traveling to corresponding areas, disinfectant or alcohol swabs should therefore not be missing in the first-aid kit.
Aftercare
Aftercare for mycetoma depends on the type of treatment and the success of treatment. If the fungal infestation can be treated by means of medication, medical aftercare is usually no longer necessary. If the infestation is not serious and is treated promptly, subsequent damage can almost always be prevented. In more severe cases, however, surgical intervention may be considered. The aim is to remove infected tissue. In some cases, little tissue is removed, although good wound care is important afterwards. Depending on the case and indication, precautionary antibiotic therapy may be useful. Follow-up examinations of the tissue for remaining pathogens are also important. Follow-up care must be communicated by the specialist and depends on the severity of the procedure. Wound healing can be achieved within a few weeks with good wound care. Further aftercare measures are not necessary once the wound has healed completely. If, on the other hand, an amputation is performed because too much tissue is affected, aftercare is more difficult. The residual limb must be treated. If necessary, further therapies are added to the aftercare. This is the case, for example, if the affected person experiences phantom pain. Learning to move despite the amputated body part is also part of aftercare. The aforementioned aftercare measures apply to eumycetomas caused by fungi as well as actinomycetomas caused by bacteria.
What you can do yourself
Mycetoma is usually treated with medication. What measures the affected person can take himself to relieve the symptoms and promote the healing process depends on the type and severity of the disease. In principle, rest and bed rest are recommended. Especially in the first days of the disease, sufficient bed warmth should be ensured to avoid spreading the pathogen. In addition, swollen or purulent areas should be carefully cared for and, if necessary, treated with gentle care products. The use of appropriate preparations should first be discussed with the responsible physician. In case of severe symptoms, surgical intervention is necessary. After surgery, the skin is usually very irritated and must not be exposed to harmful influences such as dirt or allergens. The affected person should strictly follow the doctor’s instructions and inform the physician of any unusual symptoms. Mycetoma usually heals well, provided it is treated early and a physician monitors its progress. To prevent re-infection, the causes of the initial fungal infection must be determined. For this purpose, a complaint diary can be created in which possible triggers and other abnormalities are noted.
